1. Hybrid Arch for Acute Type A Aortic Dissection
Hybrid Arch for Acute Type A Aortic Dissection Is the stent graft best served “Frozen” or “Warm” ?
Jehangir J. Appoo
Division of Cardiac Surgery
Libin Cardiovascular Institute
Cumming School of Medicine
University of Calgary
Canadian Thoracic Aortic Collaborative Meeting
April 16th, 2016

2. Today: Focus on Hybrid Arch for Acute Type A Aortic Dissection
My objectives for next 10 mins:
Introduce 1 new concept: “Warm Stent Graft” vs. “Frozen Stented Elephant Trunk”
Propose Classification System & Outcome of Systematic Review of Hybrid Arch for ATAAD
Discuss Pros and Cons of “Warm” vs. “Frozen”
Thought provoking questions on what’s next step for Aortic Community

3. Controversy: Extent of Arch Replacement in Type A Dissection
1980’s & 1990’s: Ascending only vs. Hemiarch
Today: Hemiarch vs. Hybrid Arch (Extended Arch ± Descending Aorta) 

4. Hybrid Arch for Acute Type A Aortic Dissection
What is Hybrid Arch?
Vague term – combines open chest and endovascular
Variety of techniques
No standardized nomenclature exists for discussion of technique & comparison of results

5. Systematic Review of published Extended Arch Operations for ATAAD
Smith, HN et al. (in submission)
38 publications till Fall 2015; >2,100 patients

6. Proposed Classification of Extended Arch Operations for ATAAD
Based on 2 concepts:
1) Extent of arch reconstruction: Total Arch vs. Hemiarch
2) Method of Stent Graft deployment: Frozen vs. Warm

7. Frozen vs. Warm Stent Graft:

8. Proposed Classification of Extended Arch Operations for ATAAD
Smith, HN et al. (in submission)
Total Arch Replacement
Total Arch Replacement & Frozen Stented Elephant Trunk - deployed during hypothermic circulatory arrest
Hemi-arch Replacement & Frozen Stented Elephant Trunk - deployed during hypothermic circulatory arrest
Total Arch Replacement & Warm Stent Graft - deployed after cardiopulmonary bypass

9. Systematic Review of Extended Arch Operations for ATAAD
Smith, HN et al. (in submission)
38 publications, >2100 patients
Pooled op mortality 8.6% (95%CI )
Pooled stroke 5.7% (95%CI )
Pooled spinal cord ischemia 2.0% (95%CI )
*Note: 2015 Publications from GERAADA and IRAD suggest 15-20% operative mortality

10. Conclusion of Systematic Review
Extended arch repair for ATAAD with or without distal stent grafting shows surprisingly low incidence of early mortality and major complications
Now that we know extended arch repair for ATAAD can be done safely & we have a classification system, we can discuss pros and cons of various technical options

11. Advantages of: Frozen Elephant Trunk vs. Warm Stent Graft
No requirement of Endovascular skill set – can be more widely adopted by cardiac surgeons

12. Advantages of: Frozen Elephant Trunk vs. Warm Stent Graft
No requirement of Endovascular skill set – can be more widely adopted by cardiac surgeons
No intraop fluoroscopy/hybrid room required and operative time not increased

13. Advantages of: Frozen Elephant Trunk vs. Warm Stent Graft
No requirement of Endovascular skill set – can be more widely adopted by cardiac surgeons
No intraop fluoroscopy/hybrid room required and operative time not increased
No requirement of nephrotoxic contrast agent

14. Advantages of: Frozen Elephant Trunk vs. Warm Stent Graft
No requirement of Endovascular skill set – can be more widely adopted by cardiac surgeons
No intraop fluoroscopy/hybrid room required and operative time not increased
No requirement of nephrotoxic contrast agent
More published data on this technique than “Warm Stent Graft”

15. Advantages of: Frozen Elephant Trunk vs. Warm Stent Graft
No requirement of Endovascular skill set – can be more widely adopted by cardiac surgeons
No intraop fluoroscopy/hybrid room required and operative time not increased
No requirement of nephrotoxic contrast agent
More published data on this technique than “Warm Stent Graft”
No access issues

16. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones

17. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear (SINE)

18. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear
Assessment of branch vessel patency

19. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear
Assessment of branch vessel patency
Confirmation of resolution of malperfusion

20. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear
Assessment of branch vessel patency
Confirmation of resolution of malperfusion
Distal extension of treatment

21. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear
Assessment of branch vessel patency
Confirmation of resolution of malperfusion
Distal extension of treatment
Use of tapered devices/tromboned fashion

22. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear
Assessment of branch vessel patency
Confirmation of resolution of malperfusion
Distal extension of treatment
Use of tapered devices/tromboned fashion
Extent of coverage can be individualized

23. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear
Assessment of branch vessel patency
Confirmation of resolution of malperfusion
Distal extension of treatment
Use of tapered devices/tromboned fashion
Extent of coverage can be individualized
No increase in hypothermic circulatory arrest time

24. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear
Assessment of branch vessel patency
Confirmation of resolution of malperfusion
Distal extension of treatment
Use of tapered devices/tromboned fashion
Extent of coverage can be individualized
No increase in hypothermic circulatory arrest time

25. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear
Assessment of branch vessel patency
Confirmation of resolution of malperfusion
Distal extension of treatment
Use of tapered devices/tromboned fashion
Extent of coverage can be individualized
No increase in hypothermic circulatory arrest time
Deployment at normothermia allows for nitinol stent expansion

26. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear
Assessment of branch vessel patency
Confirmation of resolution of malperfusion
Distal extension of treatment
Use of tapered devices/tromboned fashion
Extent of coverage can be individualized
No increase in hypothermic circulatory arrest time
Deployment at normothermia allows for nitinol stent expansion
Can be done in a staged fashion permitting assessment of whether stent graft is needed

27. Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk
Assessment of adequate proximal and distal sealing zones
Assessment of Endoleaks/Stent Induced New EntryTear
Assessment of branch vessel patency
Confirmation of resolution of malperfusion
Distal extension of treatment
Use of tapered devices/tromboned fashion
Extent of coverage can be individualized
No increase in hypothermic circulatory arrest time
Deployment at normothermia allows for nitinol stent expansion
Can be done in a staged fashion permitting assessment of whether stent graft is needed
Lots of sizes available off the shelf

28. 49 y.o male ATAAD
Presents to OSH – March 2015
Primary Entry Tear Distal to L subclavian artery

29. Our Current Practice: Case Example
49 y.o male ATAAD presents to OSH – March 2015
Clinical and radiologic Visceral Malperfusion

30. Intraop:
Tear confirmed distal to left subclavian artery
Arch resected and anastamosis done in Zone 2 with individual bypasses to innominate, left carotid and left subclavian
Right axillary cannulation
Moderate Hypothermia at 25oC
HCA – 14mins with continuous ACP
SACP – 28mins

31. On Table Angio - after Zone 2 Arch Reconstruction and separating from CPB
Prior to stent graft insertion
Post TEVAR

32. 6 months follow up :

34. CCS/CSCS/CSVS Joint Position Statement on Interventions for Thoracic Aortic Disease
CCC Oct.2015 – Toronto
Canadian Journal of Cardiology, In Press

35. RECOMMENDATIONS
We recommend an extended distal arch repair technique be considered for patients who present with acute Type A dissection and one of the following:
Primary intimal entry tear in the arch or descending aorta
Significant aneurysmal disease of the arch
(Strong recommendation, Low Quality Evidence)

36. RECOMMENDATIONS
We suggest that it is reasonable to consider an extended distal arch repair technique for patients who present with acute Type A dissection and one of the following:
Distal malperfusion
Concomitant descending thoracic aortic aneurysm
Young patients
Patients with connective tissue disorders
(Weak recommendation, Low Quality Evidence)

37. CONCLUSIONS:
Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data
Pooled op mortality 8.6% (95%CI )
Pooled stroke 5.7% (95%CI )
Pooled spinal cord ischemia 2.0% (95%CI

38. CONCLUSIONS:
Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data
Proposed Classification system of Extended Arch Techniques based on:
Total Arch vs. Hemi-Arch &
Frozen Stent Graft vs. Warm Stent Graft

39. CONCLUSIONS:
Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data
Classification system of Extended Arch Techniques based on
Total Arch vs. Hemi-Arch
Frozen Stent Graft vs. Warm Stent Graft
Pros of Frozen vs. Warm Stent Graft Technique
Broader applicability vs. visualization/intraop assmt

40. CONCLUSIONS:
Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data
Classification system of Extended Arch Techniques based on
Total Arch vs. Hemi-Arch
Frozen Stent Graft vs. Warm Stent Graft
Pros of Frozen vs. Warm Stent Graft Technique
Broader applicability vs. visualization/intraop assmt
Hybrid Repairs for treatment of ATAAD now entering Guidelines
2014 European Guidelines
2015 Canadian Guidelines

41. NEXT PHASE:
Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do?
Hemi-arch vs. Extended Arch ± Descending Stent Graft ?
*Recall no RCT ever done for isolated ascending aortic replacement vs. hemi-arch

42. NEXT PHASE:
Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do?
Hemi-arch vs. Extended Arch ± Descending Stent Graft
Frozen Elephant Trunk vs. Warm Stent Graft?

43. NEXT PHASE:
Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do?
Hemi-arch vs. Extended Arch ± Descending Stent Graft
Frozen Elephant Trunk vs. Warm Stent Graft
Hybrid Arch vs. Hybrid Arch + BareMetal Stent Distally?

44. Novel Hybrid Arch Techniques for ATAAD
Zone 2 Arch
Zone 2 Arch with branched stent graft

45. My objectives for past 10 mins:
Introduce new concept of “Warm Stent Graft” vs. Frozen Stented Elephant Trunk
Propose Classification System & Results of Hybrid Arch for ATAAD
Discuss Pros and Cons of “Warm” vs. “Frozen”
Provoke thought on what’s next step for Aortic Community

46. Calgary Thoracic Aortic Program, www. aorta. ca,. Jehangir
Calgary Thoracic Aortic Program,